Critical Illness Disclosure Statement

The following statements must be reviewed carefully and signed as indicated:

Yes, as the primary applicant, I would like to apply for Critical Illness Coverage

Yes, my spouse would like to apply for Critical Illness Coverage

No, I do not want to apply for Critical Illness Coverage

No, my spouse does not want to apply for Critical Illness Coverage

I the undersigned, have been shown the Critical Illness protection offered to me by our USA Benefits Group agent. I understand that I am declining the lump sum benefit to be paid to me in the event of a critical illness and that I will be responsible for my health insurance deductible as well as any out of pocket expenses incurred for time off work due to such an illness.

Further, I choose to decline the guaranteed renewable life insurance benefit offered as part of this critical illness insurance. I have had the coverage and benefits explained to me and choose not to participate at this time.

Accident Coverage Disclosure Statement

Yes, as the primary applicant, I would like to apply for Accident Coverage

No, I do not want to apply for Accident Coverage

I the undersigned have been shown the 24 Hour Accident coverage offered to me by our USA Benefits Group agent. I understand that I am declining the additional benefit to help offset my major medical deductible in the event of an accident and that I will be responsible for my health insurance deductible as well as any out of pocket expenses incurred as a result of an accident.

By typing my full name in both of the boxes to the right, I am making an electronic signature certifying that I have completely read and understand the terms above.

Please enter your full name in both of the boxes to the right. This will serve as your electronic signature.